5 mins on last days of lifeand palliative care

emergencies !

5 mins on last days of lifeand palliative care

emergencies !

Dr. Ros Taylor

Hospice Director

Hospice of St. Francis Berkhamsted

June 2012

Know who to ring !!!Know where the resources are !

• Mount Vernon Cancer Network Advice 01923 844281

• Hospices….open all hours

• Peri-patetic Marie Curie Nurse

• OOH District Nurses

Last moments of lifeLast moments of life

• Precious

• Very symbolic to be together

• Hours at bedside - focus on separation and memories

Acknowledge death is nearAcknowledge death is near

• Fundamental to good management Allows symptom control and decisions Allows final business and acceptance

• If ignore closeness to death No care of dying Inappropriate treatment

Surprise Question

“ would I be surprised if this patient died in ………..a few days ??”

Anticipate

We can see the future…..often

Clinical intuition

• Declining mobility• Distracted and distant• Breathless • Difficulty swallowing• Circulation changes• PEOPLE KNOW !!

Limit treatment to :Limit treatment to :

• Analgesia

s/c diamorphine or morphine

• Sedation if needed

s/c midazolam or levomepromazine

• Anticholinergic

s/c glycopyrronium or hyoscine

Just in Case Boxes

• 3-5 days of

–Analgesia

–Sedation

–Drying agent

–Anti-nausea

Stopping medicationStopping medication

• Stop futile medication - treat symptoms only

• If unable to swallow - use parenteral route

Syringe driversSyringe drivers

• When to use Unable to take oral medication Nausea and vomiting Dysphagia Unconscious

• What to use

Fentanyl in the last daysFentanyl in the last days

• Keep patch on at same dose death

• Add extra analgesia as morphine in a driver

The Pain of it all

Managing terminal painContinue analgesia until deathManaging terminal pain

Continue analgesia until death

If not swallowingthen s/c infusion of diamorphine with 1/3 of

previous oral morphine dose

Breakthrough pain Use sixth of 24hr opioid dose

If not had opioids Then 10 - 20mg diamorphine s/c per 24 hrs Plus anti-emetic

Terminal DyspnoeaTerminal Dyspnoea

INSPIRE

EXPIRE

Powerful words

When midazolam fails

• Short acting 1-3 hrs

• amnesic not analgesic

• in some people acts like alcohol– increase agitation and aggression

• Alcohol and benzo use affects its activity

• try Nozinan or Phenobarbitone

Terminal restlessnessTerminal restlessness

• Look for reversible cause Bladder, bowel, pain, hypoxia

• Best drug is midazolam 2.5mg – 5mg s/c midazolam

20 mg++ per 24 hrs midazolam Or lorazepam SL

Sedation

“If you want to die in your sleep you have to sleep first..”

Liverpool Care Pathway for the Dying

Liverpool Care Pathway for the Dying

?? Stairway to HeavenOr

?? Improve everyones care

to a minimum standard

Know who to ring !!!Know where the resources are !

• Mount Vernon Cancer Network Advice 01923 844281

• Hospices….open all hours

• Peri-patetic HUC Marie Curie Nurse

• OOH District Nurses